Wednesday, May 22, 2013

The Myth of the Psychiatrist as Bogeyman

Probably the most annoying aspect of being a real psychiatrist is the constant attacks on the profession. Psychiatry is unique among medical specialties in that there are a number of philosophies, special interests, critics for profit, and some might say cults out there who generate a constant barrage of criticism of widely varying quality. There are even attacks from within the field. Most medical specialists are concerned primarily with patient care, but that is not true for the self appointed critics of psychiatry who like to attack psychiatry at any possible point in time. In this negative atmosphere - real psychiatrists like me are dedicated to patient care and continue to provide a valued service that has recently been demonstrated to deliver treatment results on par with other medical specialists. Our reason for existence in the negative environment is the sole fact that we will treat severe problems successfully that nobody else will approach. Unique psychiatric training allows us to do that. So how do we explain the incongruence between what real psychiatrists do every day and how they are treated in the media? It is basically a two step process.

The first step is looking at what is said in the media and what it really means. When Senator Grassley began investigating psychiatrists and their relationships to the pharmaceutical industry on a selective basis ignoring other medical specialties despite widespread relationships between other specialists and the pharmaceutical and medical device industry what was the real message there? When the DSM5 is critiqued for being an inaccurate device designed to make as much money for the pharmaceutical industry and organized psychiatry as possible - what is the real message there? When psychiatric diagnosis is described as being totally arbitrary and lacking validity by people who think that validity has something to do with a laboratory test, what is the real message there? Let me translate it for you. It means that psychiatrists are at best totally incompetent and at their worst greedy, dishonest, manipulative, unethical, and interested basically taking money for a worthless diagnostic and treatment exercise that frequently harms people. In other words perpetrating fraud. There is really no way to sugar coat it. If all of the critiques of psychiatry in the media are accurate - that is the only logical conclusion. If you accept that position psychiatry has been devalued as an essentially worthless medical specialty.

The second critical step is to ignore all of the flaws associated with the rest of medicine. Let's forget the fact that 30% of patients entering a medical clinic will not get an adequate explanation for their symptoms even after extensive investigation with those gold standard tests. You know - the tests that mean the diagnosis is "valid". Let's forget that reliability estimates for medical diagnoses - even using those gold standard tests are no better than the so-called poor reliability estimates of psychiatric diagnoses. Let's forget the fact that diagnostic and treatment errors in medicine are common. Let's forget that treatments for medical disorders generally carry a much higher risk of death and complications. Let's forget the fact that patients with factitious disorders get admitted to general hospitals for extended periods of time and pretend that only psychiatrists can't detect a pseudopatient. Let's forget the fact that significant numbers of medical diagnoses are routinely made in the same way that psychiatric diagnoses are made. Let's forget the fact that consensus medical diagnoses by experts are common within all medical specialties. Let's forget the fact that other specialists work for pharmaceutical and medical device companies. Let's forget the fact that many specialty organizations have revenues from industries that easily exceed the revenue stream of the American Psychiatric Association (APA). Let's forget an entire list of imperfections in the practice of medicine and pretend that general medicine is perfect for the sake of comparison with with an imperfect psychiatry. We have succeeded in overidealizing medicine.

That two step dynamic of devaluing psychiatry on a purely arbitrary basis and idealizing the rest of medicine and choosing not to apply the same criticisms that are used in the case of psychiatry is the recipe for the psychiatric bogeyman that you keep reading about in the papers.

If you really believe that there is a psychiatric bogeyman - I have a bridge in Brooklyn that I can sell you.

I am a critic of psychiatry. Its good to mention this in the beginning as the reader will keep this in mind. Some of the views above are definitely obvious and 'rational', but I call them more pseudo-rational than rational. If anti-psychiatrists are irrational in their approach (which to some extent is true), at the same time we must keep in mind that why a movement against any other medical speciality is not existing in mainstream media. There is a popular notion of 'general quackery' in the medicine where all sorts of fraudulent practices are given one umbrella term. In medicine itself, all alternative therapies like ayurveda, homoepathy, reiki, accupuncture etc are treated with same attitude as if they are all lacking any empirical evidence. If psychiatry critics are accusing psychiatry on an all or none basis, devaluing the benefits of medicines, then similarly allopathic advocates simply devalue any sort of alternative therapeutic practice. If anti-psychiatry supporters are irrational and arrogant, then what about the whole medicine community who without even taking care and time to look into the empirical basis of alternative treatments, simply reject or ignore them because they are not based on modern medicine principles. Do you think that all alternative practices are just 'quackery'? Critics of psychiatry focus more on harms done by psychiatry and the over-projected reality of treatment efficacy, than questioning the basis of treatment.

Even in your psychiatry, if someone tells you that proper nutrients can also treat mental illnesses, would you take care to look into those studies which provide supporting evidence for that? I believe not, because the idea of that would not even be appealing to you because it goes against your textbooks which say that only neurotransmitters can cause illness. But what are neurotransmitters made of? Amino acids, proteins, amines etc.. Aren't these just nutrients? But pharmaceuticals do not market nutrients because there is no profit in them.

Dogmas are prevalent everywhere. What is more important is that we fight with harms and misuses and accept only what is good. Psychiatry definitely has more mal-practices and less benefits to mentally ill. Why is there no movement like 'Anti-Opthalmology', or 'Anti-Cardiology' ? When there is smoke, fire is definitely causing it. Anti-Psychiatry is a smoke and fire is somewhere there which needs to be looked.

There are no similar movements for the reasons I have pointed out in this post. It is quite easy to seen that other specialities have more complications and more serious complications. I have posted that evidence right here for people to see. If you w ere familiar with psychiatric literature you would be aware of the fact that it contains assessments of the nutritional aspect and every psychiatrist is aware of the nutritional and metabolic aspects of mental illness - at least the ones that are clinically relevant.

I would suggest you take a look at the data on the harms and benefits across specialities that you profess to know about. Leuchts study in the Br. J Psychiatry and www.thennt.com SOme of the data on the effectiveness of what are considered gold standard treatments in medicine will be shocking. As an example I am tapering off a 1 month course of prednisone for asthma. This link shows the effectiveness of that approach and I am in the 75-80% that saw no benefit: